Endoscopic management of complications of walled-off pancreatic necrosis after necrotizing pancreatitis

Background: Pancreatic pseudocyst and walled-off pancreatic necrosis/WOPN/associated with acute pancreatitis have been managed with success using nonoperative techniques.

Methods: The last two years 11 patients (pts) underwent transmural/trans-duodenal or trans-gastric/endoscopic drainage/lavage of sterile (2 pts, 18%) and infected (9 pts, 82%) WOPN. Endoscopic intervention was performed a median of 26 days after onset of acue necrotizing pancreatitis. A total of 11 pts (8 men, 3 women) with a median age of 51.5yrs (26–78 years) underwent attempted endoscopic drainage-lavage of WOPN. Etiologies of WOPN included biliary 82%, alkohol and pancreatic mass 18%. The location of of the WOPN involved the areas of pancreatic head 9%, and body/tail of the pancreas in 91%. The presenting symptoms at the time of endoscopic drainage were pain 64% (7 pts), fever 27% (3 pts) and abdominal compartment syndrome 1 patient (9%). Drainage was perform transgastrically in 10 pts (91%) and transduodenally 1 pt./9%/. In 8 pts the fluid collection was entered with the first puncture, while 3 pts required a second puncture. Bacterial culture of the aspirate was positive 45% (5 pts), a variety of microorganisms were identified, including primarily Enterococcus, Pseudomonas, and Klebsiella species. After the puncture and dilatation duoble plastic stent were placed 9 pts, single plastic stent 2 pts, and naso-biliary drainage 8 pts (72%). The median hospital stay for all patients 16 days (6–50 days). Two patients died after the procedure, related severe necrotizing pancreatitis. Technical complication included one patient of stent migration and perforation of the gastric wall, required surgical treatment.

Conclusion: Successful resolution of symptomatic, sterile and infected WOPN can be achieved using a minimal access endoscopic approach. Endoscopic intervention cannot be used “early“ in the necrotizing process. The patients with infected necrosis usually need long term naso-biliary drainage.